Failure to Integrate Hospice Plan of Care Into Resident’s Comprehensive Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident receiving hospice services had a comprehensive written plan of care that incorporated the hospice plan of care and clearly described the services the facility would provide. The resident was discharged from the hospital with diagnoses including repeated falls, Parkinson’s disease with dyskinesia, and dementia, with hospice care as the discharge disposition. A hospice initial coordination note documented goals related to pain management and visit frequencies for nursing and social work, and indicated hospice would deliver the initial hospice plan of care to the facility. However, these hospice goals and interventions were not integrated into the facility’s care plan, and the hospice plan of care was not provided to the surveyor upon request. The resident’s ADL care plan did not include the most recent hospice plan of care and lacked documentation of how the facility would coordinate or provide services to support hospice interventions. Record review for the month showed there was no comprehensive written plan of care that combined the hospice plan with facility services such as nursing interventions, ADL assistance, and pain monitoring. A NA reported knowing the resident was on hospice but not knowing the specifics of hospice care needs, including required pain monitoring frequency or comfort-focused ADL approaches, stating she had not been informed of hospice-specific interventions. An RN confirmed that the resident’s comprehensive care plan should have reflected individualized hospice goals and interventions but acknowledged she could not locate a comprehensive hospice care plan in the record. A hospice RN stated she did not provide the comprehensive hospice plan of care to the facility, focusing instead on medication management, and stated staff should have access to a hospice plan of care identifying needs and interventions. The DON stated the facility relied on hospice to manage their plan of care, was unaware whether the hospice plan had been integrated into the resident’s comprehensive care plan, and could not confirm whether hospice-related interventions such as pain, anxiety, shortness of breath management, and psychosocial support were present. The facility’s comprehensive care plan policy was requested but not provided, while the resident assessment policy required a comprehensive care plan for all admitted residents.
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